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Services & Treatment
Participating Providers
How It Works
Start An Enquiry
About TJC
Provider Credentials
Knowledge Centre

Start a Non-Clinical Enquiry

Services & Treatment
Participating Providers
How It Works
Start An Enquiry
About TJC
Provider Credentials
Knowledge Centre

Services & Treatment
Participating Providers
How It Works
Start An Enquiry
About TJC
Provider Credentials
Knowledge Centre

Bali Dental Treatment Assessment Form

Step 1 of 6

16%

Name(Required)

First Last

Date of Birth(Required)

Mobile number for Whatsapp(Required)

Email(Required)

Address(Required)

Street Address City State / Province / Region

Are you currently experiencing any of the following?(Required)

Pain

Swelling

Broken teeth

Loose teeth

Difficulty chewing

Missing teeth

Gum problems

None of the above

When was your last dental visit?(Required)

Less than 6 months ago

6–12 months ago

1–2 years ago

More than 2 years ago

Can't remember

Have you previously had any of the following?(Required)

Dental Implants

Crowns

Veneers

Dentures

Root Canal Treatment

Orthodontics

Gum Treatment

None

Section 4 – Medical History

What are you seeking treatment for?(Required)

Do you have any significant medical conditions?(Required)

Diabetes

Heart Disease

High Blood Pressure

Sleep Apnoea

Osteoporosis

Cancer History

Autoimmune Disease

None

Other

Please provide details if applicable (medical conditions)

Are you taking any regular medications?(Required)

Yes

No

Do you have any allergies?(Required)

Yes

No

If yes, please provide allergy details

Section 5 – Travel Planning

Are you actively considering treatment in Bali?(Required)

Yes

No

Still Researching

When are you hoping to travel?(Required)

Within 1 month

Within 3 months

Within 6 months

More than 6 months

Not sure

Section 6 – Decision Making

Are you comparing more than one clinic?(Required)

Yes

No

Planning To

What matters most to you?(Required)

Safety

Qualifications

Cost

Reviews

Communication

Hospital Access

Aftercare

Location

What is your biggest concern?(Required)

Infection

Pain

Complications

Appearance

Flying After Treatment

Choosing The Wrong Clinic

Section 6 –Uploads

Upload any documents you have (X-rays, CBCT Scan, Treatment Plan, Previous Quote, Implant Information)

Max. file size: 512 MB.

Upload photos of your teeth or smile

Max. file size: 512 MB.

If you cannot upload here, please email your photos directly to the clinic.

Section 8 – Final Declaration

Is there anything else you would like the dental team to know?

Consent(Required)

I understand this form is for preliminary assessment purposes only and does not constitute medical advice, diagnosis, or a treatment recommendation.

Consent(Required)

I consent to my information being shared with appropriate dental professionals for the purpose of assessing my enquiry.

Signature

Your Name
Your Name
Your Name

Full Name Confirmation(Required)

Full Name

Date(Required)

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TJC Group’s success has been driven by the willingness of patients to support one another through shared knowledge and lived experience.

Every story contributes to a growing body of information that helps future patients navigate complex healthcare decisions with greater confidence and understanding.

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Important Disclaimer

TJC Group Medical and Dental Pty Ltd provides general healthcare information, non-clinical administrative support and introductions to independent healthcare providers. TJC does not provide healthcare, diagnosis, clinical assessment, treatment recommendations or emergency assistance. All clinical decisions, treatment, pricing, informed consent and aftercare remain matters between the individual and the treating healthcare provider.
Commercial Disclosure
TJC has commercial relationships with some participating healthcare providers and may receive remuneration from those providers. Individuals are not required to use a provider introduced by TJC. Commercial arrangements do not give TJC authority over clinical decisions, treatment recommendations, pricing or patient care.

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